PATIENT-SUPPLIED MEDICATION INFUSION

DEVICES IN THE EMERGENCY DEPARTMENT:ARE YOU READY?

Author: Stacy L. Carson, PharmD, BCPS, Horsham, PASection Editor: Susan Paparella, MSN, RN

The Scenario

An unconscious 67-year-old male patient is brought intothe emergency department after being found face downon the sidewalk outside of the local mall. During the initialassessment, an unknown medical device is found on thepatient’s waist. An ED nurse was able to identify it asan insulin pump. After discovering the identity of thepatient, it was determined that he has never been seenin the hospital before, and therefore no record of his med-ical history, medications, and specifically his insulin man-agement are available.

How does your organization manage patients withinsulin pumps? Would you automatically consider turningit off? What would you do if it was an infusion pump withchemotherapy, epoprostenol (Flolan), or a patient-con-trolled analgesia pump? Turning off a device of this naturewithout proper understanding of its purpose or contentscould lead to serious and even fatal patient outcomes. Whatdoes your institution’s policy say about medication-related

devices brought in by patients? Under what circumstancesis it permissible for a patient to control his or her own med-ication and medication device?

Risky or Not?

As technology rapidly changes in health care, so does themanner in which medications are delivered. Recently, theuse of medication-related infusion devices has becomemore commonplace. For example, it is estimated that tensof thousands of people in the United States are using insu-lin pump therapy.1 For the purpose of this article, medica-tion-related infusion devices are portable infusion devicesthat assist in the delivery or administration of a medication,such as infusion pumps, patient-controlled analgesiapumps or other pain devices, and insulin pumps.2,3

Although infusion devices are commonly used in hospitals,the use of patient-supplied medication infusion deviceswithin a hospital is often controversial. Patients are oftenvery adept at managing their disease states and their ownmedication with devices (if necessary) while at home andmay expect to be able to do the same when they come intothe hospital. Oftentimes, however, this responsibility istaken away for a number of reasons.

Allowing patients to use their own medication-relatedinfusion devices while in the hospital carries a set of chal-lenges and safety risks. In most cases it may be impossibleto determine if the device is working properly or if it hasbeen maintained properly. Often, staff do not know how tooperate the device and, more importantly, how to turn itoff in emergent situations. Initially, it may be unknownwhether the patient is competent enough to manage thedevice or if the patient’s mental status has now suddenlychanged and is the reason for the visit to the hospital. Staffmay not know where to find replacement parts if the devicestarts to malfunction or runs out of power (eg, batterypower), or even how to properly load or refill additionalmedication when the device is empty.

If a patient is allowed to manage his or her medication/device, are staff aware of when the patient administers adose and how frequently doses have been administered?Prescribers also are unfamiliar with these devices and may

Stacy L. Carson, PharmD, BCPS is currently completing a Safe MedicationManagement Fellowship at the Institute for Safe Medication Practices(ISMP*). Before joining ISMP, Stacy completed 2 residencies at the Univer-sity of Kansas Hospital, located in Kansas City, KS. She completed a PGY-1Pharmacy Practice Residency in 2010 and a PGY-2 Drug Information Resi-dency in 2011.*ISMP is a nonprofit organization that works closely with health care practi-tioners, consumers, hospitals, regulatory agencies, and professional organiza-tions to educate caregivers about preventing medication errors. ISMP is thepremier international resource on safe medication practices in health careinstitutions. If you would like to report medication errors to help others,E-mail us at: ismpinfo@ismp.org or call (800)FAIL-SAF(e). This MedicationError Reporting Program keeps information confidential and secure. We willinclude only the level of detail that the reporter wishes in our publications.

For correspondence, write: Stacy L. Carson, PharmD, BCPS, Institute forSafe Medication Practices, 200 Lakeside Dr, Suite 200, Horsham, PA19044; E-mail: scarson@ismp.org.

J Emerg Nurs 2012;38:267-9.

Available online 15 March 2012.

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Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

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unknowingly write incomplete orders, leaving practitionerswithout essential patient-specific drug information.

It is important to be aware that in some cases, patientsmanage their care better than hospital personnel do (eg,diabetics with a long history of managing their insulindevice) and may be disappointed or dissatisfied with thecare that hospital staff provide when using the device.Patients need to be informed that if their condition changesor if they must undergo a variety of diagnostic studies or goto the operating room, the device may need to be turnedoff or managed by hospital personnel.

It is important to determine how such devices will behandled in your emergency department before they arrive,because varying practices on how patient-supplied infusiondevices are handled can lead to medication errors.1 TheInstitute for Safe Medication Practices urges each organiza-tion to establish and adopt a standardized approach to theuse of these devices. Although the aforementioned scenariois not uncommon, many institutions do not have a formalprocess established for managing patients when they pre-sent with medication-related infusion devices.

In 2007 and 2008, the ECRI Institute published arti-cles relating to patient-supplied equipment and how toassess and control the risk associated with their use in hos-pitals.2,3 In general, ECRI does not recommend allowingpatient-supplied medication devices to be used in hospitals,with a few exceptions (eg, insulin pumps), and then onlyafter a thorough screening of the patient’s ability to use thedevice and investigation of the device itself has been com-pleted. This screening and investigation could be particu-larly difficult during off shifts and on weekends andholidays when knowledgeable biomedical engineers likelyare not present. Each hospital should determine whichmedication infusion devices they are willing to allowpatients to use and under what circumstances.

What Can I Do?

Determine whether your institution currently has a policyregarding the use of patient-supplied medication infusiondevices in the hospital or while in the emergency depart-ment. If such a policy does not exist, gather a multidisci-plinary team, including physicians, pharmacists, nurses,and biomedical engineers, to investigate the issue anddevelop a policy. A failure mode and effects analysis wouldbe a good approach to take to determine the risk associatedwith any of these decisions. Consider the following ques-tions when developing this policy:

• Is a therapeutic equivalent (alternative) device currentlyavailable in the organization?

• Does the policy require that the pumps/devices beinspected by the organization’s biomedical engineeringdepartment upon admission to ensure that they areworking properly? If so, are members of this depart-ment available 24 hours a day, 7 days a week?

• Are the manufacturer’s directions for use of the device avail-able to staff? Are the directions easily accessible online?

• Will patients be required to demonstrate competencyduring the admission process before they are allowedto use the device? If so, who will establish their compe-tency and sign off on it?

• Is the patient’s status considered when assessingwhether the patient is allowed to control his or herown pump/devices? (For example, what if the patient isunconscious, confused, or will be under sedation fora procedure?)

• Who will supply the medication for the pump/device afteradmission? Who will fill/refill the device if necessary?

• Do all professional staff know how to turn off the devicein case of an emergency?

• Where can backup supplies (eg, a second pump, batteries,or specialty tubing) be obtained? Can these supplies bebrought in from home, or are they a specialty order?

• Are any special precautions for procedures required, suchas computed tomography and magnetic resonance ima-ging scans?

• If the device is wireless, will it work in all areas of thefacility?

• If the patient is a child, will family members control thedevice?

• If the device or drug is investigational, where will thedrug and device information come from?

• How will physicians/pharmacists order the medicationand how will nurses enter the medication onto the med-ication administration record (MAR)?

• What elements are required on the medication order (eg,name of the device, assessment of use, and settings)?

• Is the medication and/or device on the MAR so that allcaregivers are aware that the patient is receiving anothermedication?

• How will the nurse document the amount of medicationadministered on the MAR?

• Will the patient be required to sign a waiver to use his orher own device while in the hospital?

The use of patient-supplied medication infusion devicesin the ED setting brings inherent risk, but it can be donesafely when evaluated and managed in a standardized andthorough manner. Ensure that your emergency depart-ment has developed a policy to handle this common situa-tion so that staff are knowledgeable of the risk associated

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with this issue, but more importantly, so patients receivethe safest care possible.

REFERENCES1. Cook CB. Are two insulin pumps better than one? AHRQ Morb Mortal

Rounds. 2009. http://www.webmm.ahrq.gov/printviewCase.aspx?caseID=192. Accessed December 23, 2011.

2. ECRI Institute. Resources for managing the use of patient-suppliedequipment. Health Devices. 2007;36(9):294-301.

3. ECRI Institute. Patient-supplied equipment. Executive Summary, MedicalTechnology 8, vol. 3, May 2008. https://www.ecri.org/Documents/RM/HRC_TOC/MedTech8ES.pdf. Accessed February 4, 2012.

Submissions to this column are encouraged and may be sent toSusan Paparella, RN, MSNspaparella@ismp.org

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